Emergency Medical Minute

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**Emergency Medical Minute**

Our near daily podcasts move quickly to reflect current events, are inspired by real patient care, and speak to the true nature of what it’s like to work in the Emergency Room or Pre-Hospital Setting. Each medical minute is recorded in a real emergency department, by the emergency physician or clinical pharmacist on duty – the ER is our studio and everything is live.

Latest Episodes:

Podcast 851: High-Dose Nitroglycerin in SCAPE May 15, 2023

Show notes

Contributor: Aaron Lessen MD

Educational Pearls:

SCAPE (Sympathetic Crashing Acute Pulmonary Edema), formerly known as flash pulmonary edema, is a life-threatening condition due to a sudden sympathetic surge that leads to hypertensive heart failure, pulmonary edema, hypoxia, and respiratory distress.
The initial treatment for SCAPE stabilization is BiPAP to assist with ventilation.
Pharmacological treatment for SCAPE is best achieved with high-dose nitroglycerin (HDN), which induces venodilation and redistributes pulmonary edema.
Dosing should be high; boluses of HDN are given at doses of 1-2 mg every 3-5 minutes vs. infusions at 200-400 mcg/min then titrating down.
HDN leads to reduced intubations, less need for ICU admission, and shortened length of hospital stay in patients with SCAPE.

References

Agrawal N, Kumar A, Aggarwal P, Jamshed N. Sympathetic crashing acute pulmonary edema. Indian J Crit Care Med. 2016;20(12):719-723. doi:10.4103/0972-5229.195710
Paone S, Clarkson L, Sin B, Punnapuzha S. Recognition of Sympathetic Crashing Acute Pulmonary Edema (SCAPE) and use of high-dose nitroglycerin infusion. Am J Emerg Med. 2018;36(8):1526.e5-1526.e7. doi:https://doi.org/10.1016/j.ajem.2018.05.013
Stemple K, DeWitt KM, Porter BA, Sheeser M, Blohm E, Bisanzo M. High-dose nitroglycerin infusion for the management of sympathetic crashing acute pulmonary edema (SCAPE): A case series. Am J Emerg Med. 2021;44:262-266. doi:https://doi.org/10.1016/j.ajem.2020.03.062
Wilson SS, Kwiatkowski GM, Millis SR, Purakal JD, Mahajan AP, Levy PD. Use of nitroglycerin by bolus prevents intensive care unit admission in patients with acute hypertensive heart failure. Am J Emerg Med. 2017;35(1):126-131. doi:https://doi.org/10.1016/j.ajem.2016.10.038

Summarized by Jorge Chalit, OMS1 | Edited by Meg Joyce & Jorge Chalit, OMS1

Podcast 850: Cardiac Arrest - Entertainment vs. Reality May 08, 2023

Show notes

Contributor: Travis Barlock, MD

Educational Pearls:

Sudden Cardiac Arrest (SCA) is defined as when the heart suddenly stops beating. Immediate treatment for SCA includes Cardiopulmonary Resuscitation (CPR) and defibrillation. This event is commonly depicted in medical dramas as an intense moment but often with the patient surviving and making a full recovery (67-75%). This depiction has likely led the general population astray when it comes to the true survivability of SCA. When surveyed, the general population tends to believe that in excess of 50% of patients requiring CPR survive and return to daily life with no long-term consequences.

What percent of patients actually survive cardiac arrest?

SCA due to Ventricular Fibrillation (VF): 25-40%

SCA due to Pulseless Electrical Activity (PEA): 11%

SCA due to noncardiac causes (trauma ect.): 11%

SCA when the initially observed rhythm is Asystole: Less than 5%, by some measures as low as 2%.

References

Diem SJ, Lantos JD, Tulsky JA. Cardiopulmonary resuscitation on television. Miracles and misinformation. N Engl J Med. 1996 Jun 13;334(24):1578-82. doi: 10.1056/NEJM199606133342406. PMID: 8628340.
Bitter CC, Patel N, Hinyard L. Depiction of Resuscitation on Medical Dramas: Proposed Effect on Patient Expectations. Cureus. 2021 Apr 11;13(4):e14419. doi: 10.7759/cureus.14419. PMID: 33987068; PMCID: PMC8112599.
Engdahl J, Bång A, Lindqvist J, Herlitz J. Can we define patients with no and those with some chance of survival when found in asystole out of hospital? Am J Cardiol. 2000 Sep 15;86(6):610-4. doi: 10.1016/s0002-9149(00)01037-7. PMID: 10980209.
Cobb LA, Fahrenbruch CE, Walsh TR, Copass MK, Olsufka M, Breskin M, Hallstrom AP. Influence of cardiopulmonary resuscitation prior to defibrillation in patients with out-of-hospital ventricular fibrillation. JAMA. 1999 Apr 7;281(13):1182-8. doi: 10.1001/jama.281.13.1182. PMID: 10199427.
Rea TD, Eisenberg MS, Becker LJ, Murray JA, Hearne T. Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective. Circulation. 2003 Jun 10;107(22):2780-5. doi: 10.1161/01.CIR.0000070950.17208.2A. Epub 2003 May 19. PMID: 12756155.
Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O'Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM; Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916. Epub 2020 Oct 21. PMID: 33081529.

Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS1

Mental Health Monthly #15: Psychosis in the ED: Part I May 03, 2023

Show notes

Contributors: Andrew White MD & Travis Barlock MD

In this episode of Mental Health Monthly, Dr. Andrew White, a practicing psychiatrist with an addiction medicine fellowship, and Dr. Travis Barlock, an emergency physician at Swedish Medical Center, discuss the various presentations and etiologies of acute psychosis. They explore the medical presentations compared with primary psychiatric manifestations and how to narrow the differential. Furthermore, Dr. Barlock discusses the management of psychotic patients from the ED perspective while Dr. White provides invaluable insight into their respective psychiatric care.

Educational Pearls:

Auditory hallucinations are more consistent with primary psychiatric psychosis, whereas visual hallucinations are indicative of drug-induced or withdrawal psychosis.
Negative symptoms in schizophrenia can be remembered by the four A's: Alogia, Affect, Ambivalence, and Associations.
Typical primary psychosis presents before age 40, except for in perimenopausal and post-partum women, who are at higher risk of psychiatric psychosis.
Medical etiology clues: acute and rapid onset, focal neurologic deficits, abnormal vital signs (especially fever), drugs, endocrine sources, autoimmune diseases, infectious disease, and brain lesions.
To LP or not to LP? Dr. Barlock discusses indications for LP including fever, rapid onset, and change in level of consciousness.

Summarized by Jorge Chait, OMSI | Edited by Jorge Chalit, OMSI | Studio production by Jeffrey Olson

Podcast 849: Large Vessel Occlusions May 01, 2023

Show notes

Contributor: Travis Barlock MD

Educational Pearls:

Large Vessel Occlusion (LVO) is a condition where a clot blocks one of the major blood vessels in the brain, leading to a stroke.

What are the vessels that can experience an LVO?

Middle Cerebral artery (MCA)

Internal Carotid Artery (ICA)

Anterior Cerebral Artery (ACA)

Posterior Cerebral Arteries (PCA)

Basilar Artery (BA)

Vertebral Arteries (VA)

What are the locations at which a mechanical thrombectomy can be performed as a treatment for an LVO?

Distal ICA, M1 or M2 segments of the MCA, A1 or A2 segments of the ACA, and some evidence for the BA.

What are the symptoms of LVO?

Use the mnemonic FANG-D to remember a few key symptoms:

Field Cut (A person loses vision in a portion of their visual field)

Aphasia (Difficulty speaking)

Neglect (A person may have difficulty paying attention to or acknowledging stimuli on the affected side of their body or in their environment. For example, a person with neglect may deny that their left hand belongs to them)

Gaze Deviation (One or both eyes are turned away from the direction of gaze)

Dense Hemiparesis (Paralysis affecting one side of the body)

What are the treatment windows for treating an LVO?

24 hours for mechanical thrombectomy

0-4.5 hours for tPA/TNK

References

1. Brain embolism, Caplan LR, Manning W (Eds), Informa Healthcare, New York 2006.

2. Berkhemer OA, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med. 2015 Jan 1;372(1):11-20. doi: 10.1056/NEJMoa1411587. Epub 2014 Dec 17. Erratum in: N Engl J Med. 2015 Jan 22;372(4):394. PMID: 25517348.

3. Herpich, Franziska MD1,2; Rincon, Fred MD, MSc, MB.Ethics, FACP, FCCP, FCCM1,2. Management of Acute Ischemic Stroke. Critical Care Medicine 48(11):p 1654-1663, November 2020.

4. Warner JJ, Harrington RA, Sacco RL, Elkind MSV. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke. 2019 Dec;50(12):3331-3332. doi: 10.1161/STROKEAHA.119.027708. Epub 2019 Oct 30. PMID: 31662117.

5. Hoglund J, Strong D, Rhoten J, Chang B, Karamchandani R, Dunn C, Yang H, Asimos AW. Test characteristics of a 5-element cortical screen for identifying anterior circulation large vessel occlusion ischemic strokes. J Am Coll Emerg Physicians Open. 2020 Jul 24;1(5):908-917. doi: 10.1002/emp2.12188. PMID: 33145539; PMCID: PMC7593424.

Summarized by Jeffrey Olson | Edited by Meg Joyce & Jorge Chalit, OMS1

Podcast 848: Non-Traditional RSI Apr 24, 2023

Show notes

Contributor: Meghan Hurley, MD

Educational Pearls:

Two main reasons to choose non-traditional RSI

Anatomically challenging airway
Physiologically difficult patients: hypoxia, metabolic acidosis, hemodynamic instability

Ketamine may help patients remain hemodynamically stable
In critical patients, it is important to consider non-traditional RSI medications to improve outcomes

References

1. Lyon RM, Perkins ZB, Chatterjee D, Lockey DJ, Russell MQ. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care. 2015;19(1). doi:10.1186/s13054-015-0872-2

2. Merelman AH, Perlmutter MC, Strayer RJ. Alternatives to rapid sequence intubation: Contemporary airway management with ketamine. West J Emerg Med. 2019;20(3):466-471. doi:10.5811/westjem.2019.4.42753

Summarized by Jorge Chalit, OMS1 | Edited by Meg Joyce

Podcast 847: ECMO CPR Feb 06, 2023

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Extracorporeal Membrane Oxygenation (ECMO) has been attempted as an adjunct to CPR during cardiac arrest but few studies on outcomes exist
One prior small study stopped early when it showed ECMO with CPR (ECPR) was significantly superior to CPR
Recent large, multicenter randomized control study in Netherlands evaluated neurologic outcomes in CPR versus ECPR

At 30 days and 6 months no significant difference between the groups was found

More studies are required determine if certain patients may benefit from ECPR

References

Belohlavek J, Smalcova J, Rob D, et al. Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2022;327(8):737-747. doi:10.1001/jama.2022.1025

Suverein MM, Delnoij TSR, Lorusso R, et al. Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. N Engl J Med. 2023;388(4):299-309. doi:10.1056/NEJMoa2204511

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.

Podcast 846: Early Repolarization vs. Anterior STEMI Jan 30, 2023

Show notes

Contributor: Travis Barlock, MD

Educational Pearls:

Early repolarization a benign EKG pattern that can mimic an anterior STEMI
Can be seen in the anterior leads typically in young male patients
Can differentiate Early Repolarization vs Anterior STEMI by looking at four variables:

Corrected QT interval
QRS amplitude in V2
R wave amplitude in V4
ST elevation 60 ms after J point in V3

These four variables can be plugged into a formula (available on MDCalc)
Note that a longer QT is more corelated with STEMI

References

Macfarlane PW, Antzelevitch C, Haissaguerre M, et al. The Early Repolarization Pattern: A Consensus Paper. J Am Coll Cardiol. Jul 28 2015;66(4):470-7. doi:10.1016/j.jacc.2015.05.033

Smith SW, Khalil A, Henry TD, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med. Jul 2012;60(1):45-56.e2. doi:10.1016/j.annemergmed.2012.02.015

Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

Podcast 845: Hyperkalemic Cardiac Arrest Jan 16, 2023

Show notes

Contributor: Aaron Lessen, MD

Educational Pearls:

Hyperkalemia may cause cardiac arrest
Treatment of suspected hyperkalemic cardiac arrest begins with typical management of cardiac arrest including high-quality CPR, defibrillation if appropriate, and resuscitation medications

Administer calcium products to stabilize cardiac membrane and potassium shifting medications
If ROSC is achieved, initiate dialysis

There are several case reports of patients being dialyzed while CPR is ongoing, with some success

Dialysis during resuscitation may be an appropriate treatment for some patients

References

Jackson MA, Lodwick R, Hutchinson SG. Hyperkalaemic cardiac arrest successfully treated with peritoneal dialysis. BMJ. 1996;312(7041):1289-1290. doi:10.1136/bmj.312.7041.1289

Kao KC, Huang CC, Tsai YH, Lin MC, Tsao TC. Hyperkalemic cardiac arrest successfully reversed by hemodialysis during cardiopulmonary resuscitation: case report. Chang Gung Med J. 2000;23(9):555-559.

Torrecilla C, de la Serna JL. Hyperkalemic cardiac arrest, prolonged heart massage and simultaneous hemodialysis. Intensive Care Med. 1989;15(5):325-326. doi:10.1007/BF00263870

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

Podcast 844: Dental Infections Jan 10, 2023

Show notes

Contributor: Meghan Hurley, MD

Educational Pearls:

Dental infections can be categorized into two main groups

Infections of the gums

Pericoronitis

Tooth eruption leading to inflammation/irritation
Can progress to an infection
Requires pain control, no antibiotics

Gingivitis

Inflammation of the gums
Can lead to an infection requiring antibiotics

Abscess (gums)

If an infection develops in the gums it can progress to an abscess
May require drainage

Acute necrotizing ulcerative gingivitis (ANUG) aka Trench Mouth

Filmy, grayish discoloration of the gums with "punched out" lesions
Extremely painful
Can cause teeth to loosen and fall out
Treat with IV antibiotics + admission

Infections of the teeth

Dental caries

Causes sensitivity tooth enamel is worn through
Can lead to infection

Periapical abscess

Abscess that extends through the root of the tooth
Can develop up elsewhere in tooth/gums/mouth
Causes tooth sensitivity when tapped

Ludwig angina

Infection of the soft tissue under the tongue
Can compromise airway as it expands
Treat with extensive antibiotics and debridement

Antibiotic stewardship

Commonly used antibiotics for dental infections

Clindamycin
Augmentin
Amoxicillin

Chlorhexidine (Peridex)

Antiseptic and disinfectant that is helpful for gingival irritation

References

Bridwell R, Gottlieb M, Koyfman A, Long B. Diagnosis and management of Ludwig's angina: An evidence-based review. Am J Emerg Med. Mar 2021;41:1-5. doi:10.1016/j.ajem.2020.12.030

Dufty J, Gkranias N, Donos N. Necrotising Ulcerative Gingivitis: A Literature Review. Oral Health Prev Dent. 2017;15(4):321-327. doi:10.3290/j.ohpd.a38766

Herrera D, Roldán S, Sanz M. The periodontal abscess: a review. J Clin Periodontol. Jun 2000;27(6):377-86. doi:10.1034/j.1600-051x.2000.027006377.x

Kumar S. Evidence-Based Update on Diagnosis and Management of Gingivitis and Periodontitis. Dent Clin North Am. Jan 2019;63(1):69-81. doi:10.1016/j.cden.2018.08.005

Kwon G, Serra M. Pericoronitis. StatPearls. StatPearls Publishing

Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

Podcast 843: Commotio Cordis Jan 09, 2023

Show notes

Contributor: Jared Scott, MD

Educational Pearls:

Commotio cordis is sudden ventricular fibrillation precipitated by direct impact to the chest
A national registry, US Commotio Cordis Registry, reports an average of 10-20 cases annually

95% of reported cases occur in males, indicating possible genetic component
Average age of patient in registry is 15

Most cases occur during sporting events (baseball in particular), in addition to physical altercations and industrial accidents
Treatment is high quality CPR and early defibrillation

Survival rate is improving but remains around 35%

In recent events, American football player Damar Hamlin survived a Commotio cordis event after being tackled on field and receiving CPR

References

Link MS. Commotio cordis: ventricular fibrillation triggered by chest impact-induced abnormalities in repolarization. Circ Arrhythm Electrophysiol. 2012;5(2):425-432. doi:10.1161/CIRCEP.111.962712

Maron BJ, Poliac LC, Kaplan JA, Mueller FO. Blunt impact to the chest leading to sudden death from cardiac arrest during sports activities. N Engl J Med. 1995;333(6):337-342. doi:10.1056/NEJM199508103330602

Summarized by Kirsten Hughes, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD

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